Northwest Bass®, LLC

2010 Angler Registration Form

Mail to: Northwest Bass, LLC / P.O. Box 825 / Veradale, WA  99037

Name: _______________________________________________________

Address: _____________________________________________________ 

City: ________________   State: __________   Zip: ____________

Home Phone: ______________  Work/Cell Phone: _________________

SSN (required for prize payout): ___________________________ 

Email Address (this will be used to email your receipt): ______________________________

Boat Year, Make, Model:  ___________________________________

Motor Year, Make, Model:  __________________________________

Registration Fee:  (please enclose payment)

(  ) Annual Angler Registration ($50)
(  ) Single Event Angler Registration ($25 - applies to those wishing to fish only a single Northwest Bass event during the 2009 Season)

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Please sign a 2010 Release of Liability form and return with your registration.

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